ASSESSING ADULT PROTECTIVE SERVICES CLIENTS’ DECISION MAKING CAPACITY Adult Protective Services...

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ASSESSING ADULT PROTECTIVE SERVICES CLIENTS’ DECISION

MAKING CAPACITY

Adult Protective Services Core Competencies

MODULE # 17

Version 2 - Revised July 2015

Developed by the National Center on Elder Abuse and National Adult Protective Services Association

This training is a product of the National Center on Elder Abuse (NCEA), which is funded in part by the U.S. Administration on Aging under Grant

# 90-AM-2792. The project was developed by the National Adult Protective Services

Association (NAPSA), and its contractor, the REFT Institute, Inc.

Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Therefore, points of view or opinions do not necessarily represent official Administration on Aging policy.

NAPSA 2006 & 2015

NATIONAL ADULT PROTECTIVE SERVICES ASSOCIATION

NAPSA is the only national organization which represents APS professionals, programs and clients

NAPSA is the National Voice of APS

NAPSA is a partner in the National Center on Elder Abuse

NAPSA has members in all 50 states

http://www.napsa-now.org/

APS CORE COMPETENCIES

23 NAPSA Core Competencies were identified and developed into trainings for APS staff.

This module is #17: Assessing APS Clients’ Decision-Making Capacity.

For more information about APS Core Trainings, visit http://www.napsa-now.org/resource-center/training/core-aps-competencies/

TRAINING GOAL

To assist Adult Protective Services professionals in identifying the factors that affect clients’ decisional capacity and to know when and how to seek a professional evaluation.

LEARNING OBJECTIVES

Define autonomy, capacity, and incapacity. Describe factors that may influence client

capacity. Describe signs and symptoms that

indicate capacity issues. Identify key questions and approaches

used to screen client capacity, including working with special populations.

Identify implications for case planning as a result of a finding of limited capacity.

WHAT IS AUTONOMY?

‣ Autonomy is the highest principle in legal, psychological and medical issues.

‣ “Autonomy” means the right to make one’s own decisions.

Source: Kemp 2005

WHAT IS DECISIONAL CAPACITY?

Decisional capacity is the ability to adequately process information in order to make a decision based on that information.

Source: Kemp 2005

Attributes of Capacity

‣As a result of physical or mental stress.

‣According to the complexity of the decision.

‣From day to day.

‣From morning to evening.

Source: Kemp 2005

CAPACITY MAY VARY…

CAPACITY EVALUATION

A complete capacity evaluation usually includes:

A physical examinationA neurological examinationShort and long term memory assessmentAssessment of executive functionExam for existing psychological disordersDiagnosis of any existing addictive

syndromes.Source: Oklahoma APS 2005

WHAT IS INCAPACITY?

The inability to receive and evaluate information

Or to make or communicate decisions so that an individual is unable to meet essential requirements for: ‣ physical health ‣ safety‣ or self-care

Even with appropriate technological assistance.

Source: American Bar Association 1997,1998

INCAPACITY

‣Legal incapacity is a judgment about one’s legal rights and responsibilities.

‣May be partial or complete.

‣ Must be supported by evidence over time.‣ Must result in substantial harm.

‣Clinical incapacity is a judgment about one’s functional abilities.

Source: Quinn, 2005

JUDGMENT OF INCAPACITY

‣The client may lose the right to: ‣make decisions about medical

treatment and personal care‣marry‣enter into contracts‣testify in court‣participate in research‣choose where to live

ASSESSING INCAPACITY

• Age, eccentricity, poverty or medical diagnosis alone do not justify a finding of incapacity

• Can be influenced by medical conditions such as:‣ medication and medication interactions, sensory

deficits, substance abuse, mental illness

• Can be influenced by situational factors such as: ‣ substance abuse, depression, social setting, nutritionSource: Quinn 2005

Medical Conditions

These medical conditions can impact cognition:

DehydrationCongestive heart failureChronic lung diseaseUrinary tract infectionDiabetes Mini-stroke

SOURCE: Advanced Biopsychosocial Assessment: Navigating the Grey Areas

Medication Issues

Medication

interactions

Medication side effects

Adverse reaction

ACTIVITY: Differentiating the 3 D’s

Question 1 Question 2 Question 3What are the indicators that client may have a mental status problem?

Does the client appear to have dementia, delirium or depression?

What more information do you need and how would you get it?

The 3 D’s

Dementia

Delirium

Depression

Dementia Defined

It is a descriptive term for a collection of symptoms that can be caused by a number of disorders that affect the brain. It includes a memory deficit plus a deficit in at least one other cognitive domain.

Final common behavioral pathway” for many diseases/etiologies that affect the brain

Irreversible Dementias

Alzheimer’s DiseaseVascular DementiaParkinson’s DiseaseFrontal-Temporal DementiaDementia with Lewy BodiesAlcohol-related Dementia

Causes of Reversible Dementias

rugs, dehydration, depression

lectrolyte imbalances, emotional disorders

etabolic disorders

ndocrine disorders

utritional Deficiencies

rauma, tumor

nfections (urinary tract)

cute illness, arteriosclerosis complications

eizures, strokes, sensory deprivation

DEMENTIAS

Delirium

Disturbance in alertness, consciousness, perception, and thinking

Sudden onsetCaused by infection,

dehydration, changes in chemical balance, head trauma, post surgical recovery

Medical emergencyTreatable and reversible

Symptoms of Depression Yesavage & Brink, GDS, MOOD SCALE

Sleep DisturbanceLoss of Energy/ LibidoChange in Appetite/

WeightPsychomotor

Retardation/ AgitationPoor Concentration/

Attention

Symptoms of Depression Yesavage & Brink, GDS, MOOD SCALE

Anhedonia - Loss of Interest in Usual Activities

Somatic ComplaintsDysphoria - Flat AffectSense of

Hopelessness/ Worthlessness

Suicidal Ideation

CASE STUDY ACTIVITY – ASSESSING DECISIONAL CAPACITY

‣Participants are divided into small groups. Each group will be provided with a case example.

‣The task of group members is to find out as much information about their case as they can by questioning the group leader.

Components of Capacity Assessment

The client understands relevant information.• Question: Do you know that you have a serious cut on your

The quality of the client’s thinking process.

• Question: How can you get treatment for your wound?

The client is able to demonstrate and communicate a choice.• Question: Do you want to get treatment for your wound?

The client appreciates the nature of his/her own situation.• Question: What will happen if you don’t get your wound

treated?

Source: Kemp 2005

Assessment Scales and Tools

Advantages and disadvantages

When/how to useTypes of assessment tools

Cognitive Folstein Mini-Mental State Exam St. Louis University Mental Status

Exam (SLUMS) Montreal Cognitive Assessment

(MoCA) Clock Drawing Test Paradise-2

Cognitive Domains

OrientationAttentionMemoryLanguageVisual-Spatial

OrganizationExecutive

Functioning

Cognitive Domains: Orientation

Useful because standard.

Mostly tests recent and longer-term memory

Response is also influenced by level of alertness, attentiveness, and language capabilities.

If there has been a precipitous change in orientation, this could signal a critical medical condition such as delirium.

Screens: MMSE, MoCA, SLUMSSOURCE: Advanced Biopsychosocial Assessment: Navigating the Grey Areas

Nonspecific abnormalities that can occur in Focal brain lesions,

Diffuse abnormalities such as dementia or encephalitis, and in behavioral or mood disorders.

Impaired attention is also one of the hallmarks of delirium.

Screens: MMSE-registration, serial 7s; digit repetition; MoCA-digits, letter vigilance; Trails A etc.

Cognitive Domains: Attention

Cognitive Domains: Memory

Immediate memory: recall of a memory trace after an interval of a few seconds, as in repetition of a series of digits.

Recent memory: ability to learn new material and to retrieve that material after an interval of minutes, hours or days. (e.g. word lists)

Remote memory: recall of events that occurred prior to the onset of the recent memory defect. Note: this cannot be reliably tested unless you have verifiable information.

Screens: MMSE- registration, 3-item delayed recall; MoCA- registration, 3-item delayed recall etc.SOURCE: Advanced Biopsychosocial Assessment: Navigating the Grey Areas

Cognitive Domains: Language

Verbal Fluency. Refers to the ability to produce spontaneous speech fluently without undue word-finding pauses or failures in word searching. Normal speech requires verbal fluency in the production of responses and the formulation of spontaneous conversational speech.

Comprehension- Commands (MMSE fold paper; SLUMS paragraph etc.), general ability to follow directions on exams

Naming- MMSE watch, pen; MoCA camel etc.Repetition- MMSE sentencesReading/Writing- MMSE write a sentence

Cognitive Domains: Visual-Spatial Organization

Very sensitive to brain dysfunction- can pick up mild delirium and otherwise silent lesions.

In a person’s history, listen for getting lost in previously familiar environments, difficulty estimating distance or difficulty orienting objects to complete a task.

A sensitive indicator of delirium and can occur in any dementia syndrome; it often occurs early in the course of Alzheimer’s disease.

Screens: Clock drawing; Clox; overlapping pentagons,etc.

Cognitive Domains: Executive Functioning

Constellation of cognitive skills necessary for complex goal-directed behavior and adaptation to a range of environmental changes and demands.

Includes planning strategies to accomplish tasks, implementing and adjusting strategies, monitoring performance, recognizing patterns, and appreciating time sequences.

Deficits associated with disruptive behaviors and self-care limitations among patients with Alzheimer’s disease.

Screens: Clock drawing; Clox; verbal fluency tasks (category and letter); EXIT-25

MMSE (Mini Mental State Exam)

Advantages

Well-knownHuge normative data with age

and education norms Translations for all languages we

Correct administration directions printed

Quick, easy Disadvantages

Copyright issuesLow ceiling, misses mild

cognitive impairment Often incorrectly administered

and interpreted

“Spell world Backwards”

Advantages

Simple Directions/Administration

Good coverage of domains Integrates clock drawing Has education corrected norms

Disadvantages

Language translations in

developmentSome stimuli very small, Would require staff-retraining

Outside providers less familiar

“Draw a clock”

(St. Louis University Mental Status Examination)

MoCA (Montreal Cognitive Assessment)

Advantages Free Translations in many languagesMore sensitive than MMSE Interest in tool increasingDisadvantages Takes longer than MMSE More complicated to administer than MMSE

Some directions not printed on formNo clear age and education normsRelatively small normative data Some stimuli very smallOutside providers less familiar

“Name the animals”

Clock Drawing

Clock Drawing: Free Condition

Questions on 16 behaviors and cognitive functions

May be used by non-medical professionals

Questions correspond to brain functions.

Interpretation is subjective.

Source: Blum 2006

PARADISE-2

Geriatricians, geriatric psychiatrists Neurologists Neuropsychologists Nurses Occupational therapists Physicians Psychiatrists Psychologists Licensed social workers

Source: American Bar Association & America Psychological Association 2005

Clinical Professionals Qualified to Evaluate Capacity

Capacity Assessment Skills

Do your homework: know your client Educational level Language issues Cultural factors

Set the stageJoin with clientBe prepared for

responses

Considerations

Source: Quinn 2005

Client Comfort

Timing

Location

Framing the Questions

‣Assessing the client’s ability to:‣ Understand and follow instructions;‣ Understand risks and benefits;‣ Make and execute a plan.

‣Ask questions that focus on: ‣ The client’s understanding of relevant

information.‣ The quality of the client’s thinking process.‣ The client’s ability to demonstrate and

communicate a choice.‣ The client’s understanding of his/her own

situation.

CASE STUDY ACTIVITY – INTERVIEW QUESTIONS

‣Using the previous case examples, smallgroups will develop appropriate questions to evaluate the clients’ decisional capacity

CULTURAL AWARENESS

Openness to learning about other persons’ beliefs, attitudes, values and customs.

Awareness of cultures of physically and mentally challenged persons, of persons

from other ethnic groups, and countries.

Source: Lodwick 2007

CULTURALLY SKILLED INTERVIEWING

Source: Texas Department of Family and Protective Services 2004

Builds rapport

Helps get valid

information

Establishes context

for accurate analysis

Cross Cultural Interviewing Skills

‣Learn as much as you can beforehand about cultural beliefs that affect:‣ Values‣ Attitudes‣ Customs‣ Faith/religious beliefs‣ Family structure

‣ Marriage‣ Roles

Cross Cultural Interviewing Skills

Be aware that strangers are perceived as “outsiders”.

Take time to establish rapport.

Speak clearly, avoid idioms and slang.

Mirror the interviewee in tone of voice, eye contact, directness of speech.

Be respectful.

‣Never rely on the perpetrator or a family member to act as the interpreter.

‣Always use independent interpreters.

‣When using an interpreter, direct all communication to the victim.

Source: Ramsey-Klawsnik 2005

Using Interpreters

Non-Verbal Clients

‣ Ask simple “yes” or “no” questions.

‣ Ask the client to: ‣ squeeze your hand, or ‣ blink his/her eyes.

Assisted Capacity Interviewing Skills

‣When a client appears to lack full decisional capacity, it may be possible to assist their decision-making by:‣ Treating medical problems

‣ Providing information

‣ Manipulating the environment

‣ Providing encouragement and support

Source: Kapp 1990

CASE STUDY ACTIVITY – CASE PLANNING

‣Using the previous cases examples, the small groups will develop a next step for each case, based on the client capacity assessments.

‣These next steps will be presented to the large group for discussion.

Closing

ReflectionsQuestionsEvaluationsResources

NCEA: www.ncea.aoa.gov NAPSA: www.napsa-now.org/

Thank you!

ASSESSING ADULT PROTECTIVE SERVICES CLIENTS’ DECISION MAKING CAPACITY Adult Protective Services...

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